Hu and Stead Translational Neurodegeneration 2014, 3:2
http://www.translationalneurodegeneration.com/content/3/1/2
Translational
Neurodegeneration
REVIEW
Open Access
Deep brain stimulation for dystonia
Wei Hu* and Matt Stead*
Abstract
Deep brain stimulation (DBS) is an effective surgical treatment for medication-refractory movement disorders, and
has been approved by the United States Food and Drug Administration for treatment of dystonia. The success of
DBS in the treatment of dystonia depends on our understanding of the anatomy and physiology of this disorder
and close collaboration between neurosurgeons, neurologists, clinical neurophysiologists, neuroradiologists and
neuropsychologists. Currently, pallidal DBS is an established treatment option for medically refractive dystonia. This
review is intended to provide a comprehensive review of the use of DBS for dystonia, focusing mainly on the surgical
aspects, clinical outcome, MRI findings and side effects of DBS.
Keywords: Dystonia, Deep brain stimulation, Surgical outcomes, Neuromodulation, Globus pallidus
Introduction
Dystonia is a movement disorder characterized by patterned
directional and often sustained muscle contractions and
causing twisting and repetitive movements or abnormal
postures [1,2]. Dystonia is also commonly classified by
three criteria: anatomical distribution (focal, segmental, or
generalized); age of symptom onset (juvenile or adult onset)
and etiology, primary, secondary, or symptomatic. Primary
dystonias (especially generalized) are often hereditary
and may be subdivided by genotype. Although the
exact mechanism of dystonia is not well understood,
several lines of evidence suggest that the basal ganglia
play an important role in dystonia. Usually, medical
treatments are unsatisfactory and limited by side effects.
Although many focal cases and segmental dystonia may
benefit from the treatment of botulinum toxin, some
patients do not respond or become resistant to medical
treatment later [1-4]. Moreover, botulinum toxin had no
effect on the treatment of generalized dystonia [5]. DBS
was first applied in cervical dystonia by Mundiner [6] in
1977. After that, two multicenter studies on bilateral
Globus Pallidus pars Interna (GPi) DBS have demonstrated
convincing clinical benefit on a large number of patients
with primary generalized/segmental dystonia [7-9].
Accordingly, GPi DBS was approved by FDA in 2003
(as a humanitarian device exemption) for patients with
chronic, medically intractable dystonia [10-13].
* Correspondence: hu.wei@mayo.edu; stead.squire@mayo.edu
Department of Neurology, Mayo Clinic College of Medicine, 200 First Street
SW, Rochester, MN 55901, USA
Current application and outcome
All DBS candidates need to be evaluated by DBS
neurologist for assessment of the severity of dystonia &
disability level by appropriate rating scales, screening for
genetic causes (particularly DYT-1 mutation) [14,15] , or
secondary causes of dystonia. Moreover, cognitive and
psychiatric assessments are also required as baseline
measures. In our institute, the weekly Neuromodulation
Committee meeting emphasizes multidisciplinary participation from Neurology, Neurosurgery, Neuropsychology,
Psychiatry, Neuroradiology, Neurophysiology and other
specialties. Potential dystonia patient candidates for DBS
are discussed, and treatment options are considered.
Didactic presentations covering current publications in
neuromodulation is a regular component.
In order to be considered a DBS candidate, dystonic
patients should be fairly disabled and have failed medical
management. DYT-1 gene mutation test can also help us
to predict the DBS outcome as it has been reported that
DYT-1 positive patients had a better outcome [15,16].
However, the application of DBS in children with secondary
dystonia is more controversial [17-19]. It has also been
reported that duration of dystonia is negatively correlated
with surgery prognosis; patients with shorter disease
duration have more favorable postoperative outcomes. Thus,
in order to prevent secondary orthopedic complications,
DBS surgery needs to be considered earlier [15,20].
Recently, Moro E. et al. [21] nicely summarized several
key points for DBS patients selection: briefly, young
patients with primary dystonia and/or tardive dystonia
© 2014 Hu and Stead; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication
waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise
stated.
Hu and Stead Translational Neurodegeneration 2014, 3:2
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are likely to have the good outcome from DBS surgery,
however, regarding the patients with secondary dystonia,
DBS should be carefully considered, due to lack of clinical
effectiveness. Additionally, in patients with severe cervical
dystonia, a cervical spine MRI is required to quantify the
role of spinal degeneration in cervical pain [22], and to
make sure whether or not if the spinal surgery is necessary
before or after DBS [23]. Last but not the least the authors
also recommend a detail psychiatric evaluation in patients
with psychiatric history pre- and post-operatively.
Optimal target selection
Once a patient is identified to be a suitable candidate for
DBS, a target for the procedure has to be selected.
Numerous studies have demonstrated that the GPi target
can improve motor function and disability in primary
dystonia [24-27]. The effects of GPi DBS on the cardinal
symptoms of dystonia have been established in three
randomized controlled clinical trials. Vidailhet, et al.
reported a prospective, controlled, multicenter study in
2005 [8] and more recently in 2007 providing updated
results [9]. Specifically, 22 severely impaired French
patients with primary generalized dystonia were enrolled
in the study and the efficacy and safety of pallidal DBS
were evaluated with Burke-Fahn-Marsden Dystonia
Rating Scale (BFMDRS) via a blinded review of videotaped
sessions. The dystonia movement scores were significantly
improved at the three-month evaluation. The overall
quality of life was found to be improved at 1 year
and maintained at 3 years. The adverse effects of lead
fractures, infection and stimulated-related side-effects
were reported in 5 patients and were resolved without
permanent consequence. In 2006, Kupsch, et al. provided
further evidence of benefit in a multicenter, randomized,
sham-controlled, double-blind study [7]. Clinical results
from 40 patients indicated substantial improvement in
almost all movement symptoms (except speech and
swallowing), disability level, and quality of life at 6 months
post neurostimulation compared with baseline scores.
Also, at 3 months, pallidal DBS neurostimulation was
more effective than sham stimulation in patients with
either primary generalized or segmental dystonia.
Furthermore, GPi DBS has been demonstrated to
provide long term motor and functional improvement
in dystonia patients [7,27,28]. As reported in a 2 year
follow-up retrospective study of 30 patients with primary
dystonia, DBS patients were found to have excellent outcomes in motor and disability scores [29,30]. Importantly,
for DTY-1 positive patients, GPi DBS demonstrated clinical
benefit as long as ten years, however, 8 out of 26 patients
had an additional GPi DBS because of the worsening
dystonic symptoms [31]. In addition, according to a recent
literature based series of 44 patients, children and adolescents responded well to GPi-DBS with good tolerance [32].
Page 2 of 5
A few anecdotal reports suggested that the symptom
of dysphonia can also be improved in selected DBS
cases [33]. However, problems of speech and swallowing
may be more difficult to manage with DBS as assessed by
BFMDRS [7,8,34]. Worsening of handwriting and stimulation induced parkinsonism have also been reported in DBS
patients with cervical dystonia [23,35-37].
On the other hand, patients’ perceptions of life shift
after DBS should also be considered. Undoubtedly, most
DBS dystonia patients had an easier, more satisfying
life with greater confidence. However, some patients
reported that the “new life” after DBS was challenging and
stressful, because of concerning about being dependent on
the stimulator and dealing with interfering side effects
from stimulation. Those patients would need better
professional support [38].
Dystonia-choreoathetosis Cerebral palsy is a common
cause of disability in both children and adults, and
refractory to pharmaceutical treatment. A recent multicentre prospective pilot study of bilateral GPi-DBS in
13 patients identified that clinical movement score,
functional disability, pain, and mental health-related
quality of life were significantly improved one year after
DBS. The optimum therapeutic target was thought be the
posterolateroventral region of the GPi [36,39-41].
Clinically, the use of DBS is controversial in children
with secondary dystonia [19,42,43]. However, several
case reports indicated that GPi DBS was effective in
focal segmental dystonia involved in neck, facial, trunk,
upper and lower limbs [44-50]. Interestingly, the
combined targets of ventral intermediate nucleus
(Vim) plus GPi DBS significantly improved Myoclonus
Dystonia, a rare form of movement disorder with
epsilon-sarcoglycan gene mutations and prominent action
myoclonus plus dystonia [51]. Recently, the subthalamic
nucleus (STN) has also been reported to be useful target
in dystonia patients [10,52,53], Sun et al. proposed that
STN DBS could potentially have following advantages
over GPi DBS: immediately symptomatic improvement
after programming, the lower stimulation parameters with
longer battery life; and finally, STN DBS results in better
symptomatic control [53]. However, currently, the data is
limited and there is a lack of head to head comparisons
between STN and GPi stimulation for dystonia. In
contrast, secondary dystonia had a less robust response to
DBS intervention [54]. The presumed reasons are that
secondary dystonia is a complex movement disorders with
a combination of hyperkinetic and akinetic-rigid dystonia,
the DBS targeted structure often has lesions, and the
dystonia is a progressively pathological process [32,50].
Taken together, although GPi stimulation is currently
being regarded as the main DBS target for primary
dystonias, focal, and segmental dystonias with substantial
clinical benefit, we should continue studying the potential
Hu and Stead Translational Neurodegeneration 2014, 3:2
http://www.translationalneurodegeneration.com/content/3/1/2
A
T1-weighted axial sequence
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B
T2-weighted axial sequence
Figure 1 Postoperative magnetic resonance images for the targets of bilateral Globus Pallidus Pars Interna from a representative
patient. (A) T1-weighted and (B) T2-weighted axial sequences are shown with the target highlighted with black dots.
benefit of other targets, particularly for secondary dystonia
patients [27].
In our institute, intraoperative MRI has been routinely
used in the DBS procedure. Specifically, post-implant
imaging is supervised by an MR imaging physicist to
maintain the specific absorption rate below the required
level of 0.1 W/kg and always includes T1 magnetizationprepared rapid gradient echo and T2* gradient echo
sequences with selected use of T2 fluid attenuated inversion
recovery (FLAIR) and T2 fast spin echo (FSE). Recently,
our DBS group demonstrated that intraoperative MR
imaging during DBS lead placement can be performed
safely to confirm lead placement prior to finalizing the
surgery in all dystonia patients (Figure 1) [55]. Furthermore,
since 1998, our department has used computer-aided
subtraction ictal SPECT co-registered to MRI (SISCOM)
to improve the clinical usefulness of SPECT in localizing
the surgical epileptic seizure foci [56]. In 2010, we developed a statistical parametric mapping and MRI voxel-based
method of analyzing ictal-interictal SPECT difference data
(statistical ictal SPECT coregistered to MRI [STATISCOM])
and were able to determine whether the ictal-interictal
subtraction difference is statistically different from the
expected random variation between 2 SPECT studies
and to further improve surgical accuracy and increases
probability of seizure freedom for patients with epilepsy
[57]. Based on the experiences obtained from epilepsy
patients, recently, our DBS group had obtained Technetium
99 m Neurolite SPECT scan of the brain in the dystonia patient with awake state and under anesthesia,
Figure 2 Computer-aided subtraction SPECT imaging in a patient with severe dystonia. The patient was 35 years old with long history of
cervical dystonia and choreoathetotic movements. We obtained Technetium 99 m Neurolite SPECT scan of the brain in this patient with awake state and
under anesthesia, respectively. Subtraction SPECT imaging had shown a hypermetabolic left caudate (blue), which is helpful for DBS target selection.
Hu and Stead Translational Neurodegeneration 2014, 3:2
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respectively. Then subtraction analysis was performed
to determine whether the awake (dystonia)-sleep
(non-dystonia) subtraction difference is statistically
different and to further identify the target for DBS. We
found that the location of hyperactivity (hypermetabolic)
on the subtraction images in the brain could potentially
help us to identify the optimal DBS target (Figure 2,
unpublished data).
Side effects
Overall, DBS patients tolerated the procedure fairly well
[58], however, clinically, asymptomatic hemorrhage due
to the DBS procedure may be difficult to be identified.
Recently, our group found that intraoperative MRI is
helpful in identifying acute changes involving intracranial
hemorrhage and air during DBS surgery, given the fact
that these findings are usually clinically silent and
often resolve prior to follow-up imaging. We identified
that selective use of T2 FLAIR and T2 fast spin echo (FSE)
imaging can confirm the presence of air or hemorrhage
and preclude the need for CT examinations [55]. On the
other hand, hardware related complications including
infection and electrode lead displacement, lead or extension
fractures, may occur more frequently in dystonia as prominent axial movements cause more mechanical stress.
These patients are more likely to complain of stimulation
related adverse effects of speech problems, such as dysarthria
and dysphonia It should be noted that, despite the fact that
most studies indicate that bilateral GPi stimulation does not
have significant adverse effect on mood or cognition in
dystonia patients, several suicides cases have been
reported in GPi DBS dystonia patients. All of them had
depression at baseline and it is still unknown whether
the suicide was related to the DBS stimulation [59]. As
such, close monitoring should be warranted in these
patients, given reports of postoperative suicide [60].
Possible mechanism of action of DBS
Due to the unknown pathophysiology of dystonia [61],
the knowledge about the mechanism about GPi DBS in
dystonia is very limited. It appears that the time between
the stimulation beginning and onset of symptom relief is
longer (days to weeks) as compared to PD (minutes)
[53]. It is plausible that GPi DBS increases output
from the stimulated nucleus and activates surrounding
fiber pathways, subsequently resulting in a complex
pattern of excitatory and inhibitory effects that modulate the entire basal ganglia thalamocortical network.
The stimulation-induced regularization of neuronal patterns
prevents transmission of pathologic bursting and oscillatory
activity within the network, resulting in improved
processing of sensorimotor information and reduction of
disease symptoms [62].
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Conclusion
DBS provides relief of the main symptoms of dystonia. It
is plausible that the clinical benefits of DBS are due
to the disruption of the pathological activity in the
cotical-basal-gangalia-thalamic-cortical motor loop. Better
understanding the mechanism of DBS will undoubtedly
help more dystonia patients for long term benefit.
With the advent of advanced neuroimaging, like SISCOM,
STATISCOM, and 7-Tesla MRI, experienced DBS doctors
will be able to optimal DBS target selection and identify
the most suitable candidates for it [24]. In addition,
new exciting developments of DBS technology is quickly
evolving, currently, it is plausible for DBS programmer to
have more flexibility in stimulation programming and
increased battery duration. Increasing evidence will also
help us to apply DBS in secondary dystonia patients and
explore potential new optimal target for DBS [21]. Finally,
the success of DBS treatment in the dystonia depends
on our understanding of the anatomy and physiology
of this disorder from basic scientists, and involvement
of neurologists, neurosurgeons, neuroradiologists and
neuropsychiatrists in outcome studies of DBS surgery.
Competing interests
Dr. Matt Stead is the director of deep brain stimulation program at Mayo
Clinic, and serves on the Medtronic Medical Advisory Board.
Authors’ contributions
WH and MS have written the manuscript draft, Both authors read and
approved the final manuscript.
Received: 6 December 2013 Accepted: 19 January 2014
Published: 21 January 2014
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Cite this article as: Hu and Stead: Deep brain stimulation for dystonia.
Translational Neurodegeneration 2014 3:2.